Provider Demographics
NPI:1417636010
Name:HUMPHREY, ELIZABETH ANN (OC61206907)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:OC61206907
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8726 DRESDEN LN SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-4617
Mailing Address - Country:US
Mailing Address - Phone:253-244-2414
Mailing Address - Fax:
Practice Address - Street 1:8726 DRESDEN LN SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98498-4617
Practice Address - Country:US
Practice Address - Phone:253-244-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC61206907225X00000X
224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist